Reference no: EM13924

INTRODUCTION

The U.S. health care system is the subject of much polarizing debate. At one extreme are those who argue that Americans have the "best health care system in the world", pointing to the freely available medical technology and state-of-the-art facilities that have become so highly symbolic of the system. At the other extreme are those who berate the American system as being fragmented and inefficient, pointing to the fact that America spends more on health care than any other country in the world yet still suffers from massive uninsurance, uneven quality, and administrative waste.

了解这两个截然相反的观点之间的辩论需要对美国卫生保健系统的结构有基本的了解。这个底漆会
解释系统的组织和融资，并为美国医疗保健提供
在更大的国际背景下的系统。

美国医疗保健系统组织

As with all other countries, there are both private and public insurers in the U.S. health care system. What is unique about the U.S. system in the world is the dominance of the private element over the public element.

2003年，有62％的非高级美国人获得了私人雇主赞助的保险，而5％的非雇主在私人非集团（个人）市场上购买了保险。15％的人参加了公共保险计划，例如医疗补助计划，而18％的人没有保险。年龄在65岁或以上的老年人几乎均匀地招募了Medicare。

Public Health Insurance

• Medicare

o Basics: Medicare is a federal program that covers individuals aged 65 and over, as well as some disabled individuals.
o政府：Medicare是政府管理的单一付款计划；单付款人是指这样的想法，即只有一个实体（政府）执行报销保险职能。
o Financing: Medicare is financed by federal income taxes, a payroll tax shared by employers and employees, and individual enrollee premiums (for parts B and D).
O福利：Medicare A部分涵盖医院服务，Medicare B部分涵盖医师服务，而Medicare D部分则提供了处方药益处。[Medicare C部分是指Medicare Advantage -HMO的管理Medicare福利]。

医疗保险的覆盖范围有很多差距，包括熟练护理设施的不完整覆盖范围，不完整的预防性护理覆盖范围以及牙科，听力或视力护理的覆盖范围。因此，绝大多数参与者获得了补充保险。

Overall, seniors pay about 22% of their income for health care costs despite their Medicare coverage.

• Medicaid3

O基础知识：Medicaid是为低收入和残疾人设计的计划。根据联邦法律，各州必须涵盖非常贫穷的孕妇，​​儿童，老年人，残疾和父母。没有孩子的成年人没有覆盖，许多穷人的成年人却有太多的资格获得医疗补助。
？States have the option of expanding eligibility if they so choose. For example, states can choose to increase income eligibility levels.

o Administration: The states and the District of Columbia are responsible for administering the Medicaid program; as such, there are effectively fifty-one different Medicaid programs in the country.

o Financing: Medicaid is financed jointly by the states and federal government through taxes. Every dollar that a state spends on Medicaid is matched by the federal government at least 100%. In poorer states, the federal government matches each dollar more than 100%. Overall, the federal government pays for 57% of Medicaid costs.

o Benefits: Medicaid offers a fairly comprehensive set of benefits, including prescription drugs. Despite this, many enrollees have difficulty finding providers that accept Medicaid due to its low reimbursement rate.

•其他公共系统

o S-CHIP: The State Children's Health Insurance Program (S-CHIP) was designed in 1997 to cover children whose families make too much money to qualify for Medicaid but make too little to purchase private health insurance. S-CHIP and Medicaid often share similar administrative and financing structures.

O VA：退伍军人政府是一项为退伍军人的联邦政府管理计划。医疗保健在政府拥有的VA中提供

私人健康保险

• Employer-sponsored insurance

o Basics: Employer-sponsored insurance represents the main way in which Americans receive health insurance. Employers provide health insurance as part of the benefits package for employees.

o管理：保险计划由营利性（例如Aetna，Cigna）和非营利组织（例如Blue Cross/Blue Shield）管理。

？特殊案例由“自保”的公司代表 - 也就是说，他们直接支付了员工直接产生的所有医疗保健费用。在这种情况下，公司与第三方合同管理健康保险计划。自保险的公司倾向于
be larger companies such as General Motors.

o融资：雇主赞助的保险是通过雇主（通常支付保费的大部分）和雇员（支付其余保费）的资金。2005年，年度私人雇主赞助的保险费平均为4,024美元，单件承保范围为4,024美元，四口之家的覆盖范围为10,880美元。

o Benefits: Benefits vary widely with the specific health insurance plan. Some plans cover prescription drugs, while others do not. The degree of cost-sharing (co-pays and deductibles) varies considerably.

• Private non-group (individual market)4

o Basics: The individual market covers part of the population that is self-employed or retired. In addition, it covers some people who are unable to obtain insurance through their employer. In contrast to the group market (employment-based insurance), the individual market allows health insurance companies to deny people coverage based on pre-existing conditions.

o管理：计划由私人保险公司管理。

o Financing: Individuals pay an insurance premium out-of-pocket for coverage. Risk in the individual market depends only on the health status of the individual, in contrast to the group market, in which risk is spread out among multiple individuals. As such, low-risk, healthy patients will have a low premium, whereas the opposite is true for high-risk, sick patients.

o Benefits: Benefits vary widely with the specific health insurance plan.

1.批判性地检查美国医疗保健系统结构的局限性。

2.讨论我们医疗保健系统财务结构中明显的管理沟通挑战，尤其是与健康差异，未投保的和功能沟通挑战有关的挑战。

3. Describe specific recommendations to improve the quality of care and the quality of communication between insurance companies, government, healthcare providers, employers, and patients.

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